| 26 February 2016
Dear Interested Readers,
What’s Inside This Week’s Letter
I like anniversaries and milestones. This letter begins the ninth year that I have practiced this habit of using a weekly letter to try to make sense of the volatile word of healthcare. The first letter went out on February 22, 2008. George Bush was President and Lehman Brothers was still in business. Except for the first three weeks of November 2013 there has been a letter every week. That is over 400 letters containing about 1.5 million words. Since I copy and paste a lot from the work of those whom I admire, let’s just say something over a million words from me. That’s War and Peace plus Gone with the Wind plus a lot of Moby Dick. Come to think of it, if you are a regular reader you might have gained more by reading one of those great books.
I thought that I had finished writing after the letter on October 25, 2013 because my retirement had been announced and Atrius Health was in the early stages of transition. I began the letter as a weekly communication effort with our staff that I hoped would be more attractive and effective than the traditional institutional memo. After announcing my retirement, I felt that writing to staff any longer would be confusing for them and unfair to those who would be leading the practice. I was tired and reasoned that retired guys just retired. I will be forever grateful to John Gallagher for challenging me to continue to write to those readers who were outside of Atrius Health and had asked to be included in the weekly distribution. Continuing to write has been a great joy for me and creates an unavoidable challenge to stay current as well as to be able to provide commentary that is worthy of your time and attention.
This week’s letter is not about the Triple Aim. I am sure that at some point in the future I will specifically return to the Triple Aim itself, and I will continue to connect the Triple Aim with what I am writing whenever and wherever bringing it up adds to the issue being discussed, as it does this week. This week’s letter is about a reality that we will continue to process into the future, concierge medicine.
Gerald Coogan, one of my new walking buddies in New London is a consultant to town and city government in New Hampshire and a person who is very aware of the political realities of our times. He sent me an email last week that contained a recent article from the New York Times that had escaped my attention: Founded for the Poor, Mass General Looks to the Wealthy. I have never written about concierge medicine, although I have thought a lot about it since it was first introduced as an alternative form of practice in the mid nineties. I hope that you will send me your thoughts on this subject and what its existence says to us now.
Once again I am writing about my memories and personal opinions. The first half of the letter with its diversions into healthcare in the UK and a review of education and civil rights in the South as I experienced it, are an attempt to give you perspective and some personal background so that you may better understand where I am coming from when I discuss some of the concerns that I have about concierge medicine. It is not quite a memoir but there are elements of that literary form. I have made every attempt to be accurate, but as I have said before I have a septuagenarian’s memory and some of the material goes back a long way.
If you missed the four week tour of the Triple Aim that was just completed let me recommend that you check out strategyhealthcare.com. The four part series has been reduced to three postings. Even more important is that about 15,000 words were condensed to about 5,000 over the three pieces. I hope that if these letters come up in conversation with your friends and colleagues that you will tell them that strategyhealthcare.com is where they can sign up to get this letter each and every Friday.
Concierge Medicine, a Jump to Solution of Sorts for Some
When I first heard about concierge medicine in the mid nineties and began to see a few physicians in my community experiment with it as a new form of practice my first reaction was, “Harley Street has come to Beacon Street”. I was being facetious and I think that I was also being inaccurate. The truth in my statement was that since the nineteenth century Harley Street in London has been the center of private practice in the UK. If you watch Downton Abbey, Lady Mary Crawley probably took her maid, Anna Bates, to Harley Street when they went to London to get the help of a gynecologist because of Anna’s recurrent miscarriages. These days Harley Street is one place where the English who want to avoid the wait for specialists in the National Health Service (NHS) can go to get private care. On Harley Street there are private physicians, mostly specialists, private hospitals, and in Britain, as in most other European countries, there is private health insurance market.
Robert Wachter is a Professor of Medicine at UCSF. I discussed his most recent book, The Digital Doctor, after he spoke at the IHI meetings in December. Dr. Wachter is also a medical blogger. A few years ago he spent some time in England and wrote a fabulous posting in January 2012 entitled The Awkward World of Private Insurance in the UK. What comes through is that there is an interlocking nature between “Harley Street” and the NHS. Most Brits are quite satisfied with access to their salaried National Health Service general practitioner, but they complain about waiting times for specialists. Tony Blair’s government did shorten the waiting times to see medical specialists and surgeons but the NHS regulations also allow NHS specialists to have unlimited private income and many do take advantage of this opportunity. About 10% of people do have some private insurance coverage and there are some private hospitals, but the care in the private facilities is poor compared the NHS facilities, though some NHS hospitals are beginning to take private patients as a way of augmenting revenue.
Reading Wachter’s description of the system in the UK reminded me that my tangential experience with ulta exclusive care in Boston had been similar. If one was really sick the last place in the world you would want to be was in the old Phillips House at the MGH where many of Boston’s Brahmins saw their famous specialists before going on to their reward. Even more elegant was the top floor of the Brigham Tower where few house staff ever ventured. The service was fashioned after the Ritz and the accommodations were more like small apartments than hospital rooms. The medical care was summed up by the reality that you were “near a hospital”.
Wachter says that in the UK the private specialists are often splitting their time between the care of their NHS patients and their private patients, with the private clientele not having the back up that the NHS patients have. Poor care for more money seems to be the trade off when a patient tries to buy care from one individual. Healthcare now is not a solo act. To be good healthcare requires the coordinated services of many professionals which is hard for a concierge system to engineer. The ability to get your care in Ritz-like extraordinary accommodations is a status symbol, I guess. Since it sells, it must be true that it is hard to beat that feeling of being “special” even if it means your care could be compromised when you are really sick.
There has always been something a little awkward between the very rich and famous and their physicians. Most physicians enjoy the traditional relationship and social position that their profession grants them. The doctor patient relationship changes a little when the patient pays more for extra attention. History certainly suggests that our Presidents have occasionally gotten something less than the best of care. Perhaps you know of the fascinating books, The Pathology of Leadership and The Mortal Presidency: Illness and Anguish in the White House. Both books raise questions about the doctor patient relationship between physicians and the elite. Getting good care is not always easy just because you are rich and famous or can afford to find someone who will take money to give you special care and access. The risk even applies to the “stars”. Think Elvis and Michael Jackson.
After thinking about “Harley Street” and the disadvantages of the elite, my next thought as I tried to orient myself to concierge medicine was to explore whether the same principles existed between concierge medicine and standard care that exists between private education and public education. I have had personal experience with both as well as experience with the strange reality of going to segregated schools. The education system in the South when I was young was really a three tiered system. There were a very few private school in large cities. Some children did go away to prep schools or “military academies” but most of us went to public schools that were divided into a system for the white and another for those who were black. There was little pretense that the systems were equal and they were very separate.
I went to good schools with a student body that was a mirror image of the (caucasian) population. The state universities were widely popular, as they are even now, and so I went to the University of South Carolina with no sense that I was missing anything. By accident of time and space rather than design, my education gave me a familiarity with a more diverse population and I believe that was of benefit to me when I began to see patients and has been a continuing benefit throughout all aspects of my life.
As I moved out of the world of my childhood and came to the Northeast for my graduate education, one of the first pieces of cultural shock that hit me was the region’s tradition of highly selective private education. In my “private” elite medical school (private does not mean that it did not get millions of dollars in public money through grants) I discovered that many of my classmates had never experienced a “public school”. For a while I felt disadvantaged. Gradually, I realized that because resources in the public world had been a bit more scarce and the environment a little bit more difficult to navigate, I had been forced to develop skills that all but the very best of my classmates did not have, since their way had been defined by the wealth of opportunities that had been given to them without much effort on their part.
Despite accepting my “public education” as something that I could not change, I did envy my classmates who had received a “concierge” education. Their classes had been smaller. They had experienced faculty with better known accomplishments. The capabilities and goals of the average students in their classes may have been higher than those with whom I had studied. Their experience had been different.
Later, however, I began to see that their different experience was not necessarily better than mine. I needed to do more for myself in the public system and had been forced to learn how to contend with circumstances that they never confronted. After an initial period of shock and an early concern that I was hopelessly “behind”, I eventually realized that what made the most difference for all of us lay in the future. What I had learned was more than enough.
As I continued to think about concierge “education” and concierge medicine, it was obvious that there was an element of class difference in it that I did not like and that confused me. I wanted to believe that this is a free country and if someone choses to buy a first class ticket on an airplane that is their right. If my neighbor wants to pay more than 30K a year for each of his several children to ride a bus across town to a famous private school, or send them away to a boarding school even though the towns where we lived offered a great public school education, that was none of my business.
It did not take me long to reject my rationalization that first class travel, private education and concierge healthcare could all be rationalized the same way. If you chose a first class ticket it does not usually affect my ability to go economy. Both ends of the plane will arrive. As long as public vouchers were not used to support the existence of private schools my neighbor’s sense of satisfaction with his children’s private school did not necessarily limit the education my children received in the public school.
There is much more potential conflict in healthcare between those wanting to go first class and those wanting to fly tourist. There should be real concerns about a healthcare system with economic tiers. As I thought more about the scarcity of primary care physicians being made worse by good PCPs opting for concierge practice, I was concerned. I became further concerned when I thought about how the overuse and waste that could be generated by a system when people were paying for access to doctors. For business success those physicians might be overly solicitous in an attempt to satisfy expectations and order tests and procedures that added no value. A system of concierge care could contribute to the medical loss ratio and the rates everyone else pays when physicians make clinical decisions to accommodate concerns or fears of patients who are not amenable to “choosing wisely”. I became concerned that concierge care could theoretically make the climb to the Triple Aim harder.
Then I realized that we have a huge “public investment” in healthcare that made concierge care even more objectionable in its inherent inequality in access. I had received large amounts of government support as grants and low interest loans for medical school. Harvard, the “private elite medical school” that I had attended, had received hundreds of millions of dollars of direct and indirect public support over the years. If the public had paid to create me as a resource and had invested in every other physician, did I, or any other physician, have the right to use a special payment process, like a retainer payment, as a de facto denial of access to patients who could not pay more? Was it right for a hospital that accepted public funds for training programs and financial support for new buildings to skew its book of business to better serve the rich?
As I thought about the six domains of quality: patient centeredness, safety, efficient, effective, timely and equitable, concierge medicine was offering patient centeredness and timely service to those who could pay more. Even if care was safe (which my hospital experience with “exclusive patients” led me to question), what did it do to efficiency, effectiveness, and above all, equity? How does concierge medicine support the Triple Aim? I think not at all, and is, in fact, a threat to it.
Can you imagine changing the Triple Aim to “Your personal Aim”?
Care better than you have ever seen, health better than anyone else has, as long as you can pay a little extra, …just for you and yours, every time.
My world was really quite out of balance as I began to follow the threads of reality about what concierge medicine really meant and what my own attitudes and rationalizations were that allowed me to be comfortable in a world where inequality in education (segregation) and healthcare (the uninsured and underinsured) were such accepted realities. In retrospect, my own little version of liberal guilt got triggered by having to think honestly about what bothered me about concierge medicine. I realized that while I was quite smugly embracing concepts of quality and safety, even efficiency and effectiveness, I too was ignoring “equity” big time and the concierge focus on access at a cost was shining a bright light on some of my own hypocrisy.
Our organization, Harvard Community Health Plan was designed to pursue the principles of the Triple Aim as it was understood in 1969. We had begun with a small federally funded outreach to the underserved but after a few years that program had closed and most of its patients had gone to Federally Qualified Health Centers in the same neighborhood. We had evolved in the seventies and eighties to care for employed people. Right off the bat that meant that compared to the general population we had very few of the elderly, little or no Medicare, and virtually none of the underserved Medicaid population. In essence we were a system designed largely for families and business people.
We were attracting patients and families who were looking for innovation in care delivery and those patients were often the educated and more affluent members of the middle class like lawyers, university faculty, school teachers, government employees including governors, judges and legislators, people in high tech companies and business people and employees of businesses interested government, consulting and academia. In the mid nineties we actually had a population analysis done that revealed that our average adult patient had more than a college education and an income well above the median income in our community. In a way we were not that much different than our colleagues who were interested in offering concierge services and our patients were not that different either.
I can remember flying into Logan on a Sunday evening as I was returning from a weekend in Atlanta visiting my parents. As the plane landed and everyone began to fire up their cell phones, I heard a familiar voice several rows in front of me. It was the voice of a concierge physician who I knew and had always respected as a critical thinker going back to when we were both in residency. He was calling his answering service to collect the calls that had come in during the less than three hours of the trip. I felt pretty sorry for him because I was quite sure that any calls from my patients had been well managed by a colleague in our collaborative practice.
It occurred to me, as I eavesdropped on the half of the conversation that I could hear as he began to call a patient even before we had completed our taxi to the terminal, that with our medical home, our focus on Lean redesign of our workflows, with our electronic patient portal and our culture of collaborative care, we were actually offering a better service with no retainer fee! Never-the-less, until we expanded our practice to Medicare and Medicaid, we were de facto restricting the access to our practice to those from whom we could make a profit. My concierge colleague was a little bit like the Pony Express, a good idea for a short time, that a better product would make obsolete. We were actually the better product but with a flaw of our own if you considered equity.
The Annual Oration that I presented at the Massachusetts Medical Society in November of 2012 was an expansion of those ideas. It was about our ability to transform with the vision of using the multiplying effect of working better together to provide the time for us to offer the individual attention and access at key moments that our patients want so desperately. My dream was that we could offer something much better than concierge care to everyone!
Perhaps I should add one other thought that hits me now whenever I think of concierge medicine. You can see it for yourself on YouTube (please take four minutes to see it). If you are a regular reader with a great memory you have heard this before. I am not perseverating yet, though I do frequently repeat my thoughts for emphasis. Here is the story if you do not know it and do not have time to click on the link.
You might remember that Helen Hunt won an Oscar for her 1998 role in As Good As It Gets. It is the story of a single mother struggling to make it as a waitress in New York. Her healthcare is provided by an HMO that will not provide her asthmatic son with the care he needs. Access is a big issue. Jack Nicholson plays a customer at the restaurant who is a wealthy writer with poor social skills, though he enjoys their daily contact as she serves him breakfast each morning. He decides to win her affection or at least more of her attention by providing her son with better healthcare, essentially from a concierge physician who will come to her apartment.
The physician is played by the great Harold Ramis, the genius behind Groundhog Day, and the intellectual, Egon, from Ghostbusters. You may have an Egon action figure in your collection of memorabilia. The good doctor comes to the apartment and is everything her HMO is not. He is literally like the Norman Rockwell painting of the kindly family doctor. The contrast between his personalized care and the run around at the HMO launches Hunt’s character into a soliloquy of damnation about the awful care her son has received. I can remember fidgeting in my seat as the scene developed and then sinking into the darkness as everyone in the theater stood up and applauded the screen when her rant was over. I knew at that moment that managed care 1.0 was over and that transformation was a necessity, not an intellectual exercise, if our practice, still thought of by many as a staff model HMO, was to survive. We had to be better than concierge medicine for everyone.
When my friend emailed me the article about the Mass General’s foray into concierge medicine I am sure that he had no idea that his action would produce such a flood of memories and feeling from me. I also thought that I should give you some background for my response to the article and the idea of paying extra for access and attention at one of our nation’s most important academic medical centers.
The title of the article says a lot that may have been lost even on its author: Founded for the Poor, “Mass General Looks to the Wealthy”. In 1811, the standard of practice was concierge medicine. Indigent patients could not pay for individual attention and were “warehoused” at eleemosynary institutions like the Mass General, which sat in the malaria infested tidal swamp at the foot of Beacon Hill. Who knew then that 205 years later the tables would have long since turned and the poor would be outside and those with excellent insurance coverage plus a little more would get concierge care from this great hospital? I write about adaptive change taking a long time but Atul Gawande has pointed out, using the advent of anesthesia in the “Ether Dome” of the MGH as an example, that there is nothing that is adopted faster than something that makes a doctor’s job easier. I will modify that and say, nothing is adopted faster than an idea designed for the possibility of greater revenue. The MGH is not alone among academic medical centers with an origin of care for the underserved now focused on what they can do for the wealthy that might produce more revenue, not only from the wealthy of this country but also from a world wide market.
The concierge practice at the MGH is scheduled for launch this summer. I am surprised that this has not happened sooner. If the article is correct the charge will be an additional $6,000 over what the patient’s insurance will pay. The offering is pretty typical in that the 6k will provide 24 hour access for patients to their doctor as well as some wellness services. Well, not quite 24 hour by 365 access, since I assume that the three doctors who will start the practice will provide each other some relief.
The article quotes Dr. Michael Jaff, the medical director of Mass General’s Center for Specialized Services and a professor at HMS,
“A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider.”
That is certainly a statement of the obvious. Another quote in the article that is at least half right comes from Dr. Wanda D. Filer, president of the American Academy of Family Physicians,
The upside is that it gives more time for patient-physician interaction, and the data shows that generally the more time a patient has with a physician, the better the outcome...The downside is that it can be very exclusive and difficult for middle- and low-income patients to afford. So there’s a concern that you’ll have a two-tier system.
For balance we are offered a quote from Pauline Rosenau, professor of public health at the University of Texas Health Science Center in Houston:
“It’s worrisome, unless you’re rich. As for the hospital’s historical mission ...I’d say it’s in jeopardy.”
The article has other quotes from people at the MGH who justify the service as a source of revenue to protect its “core” mission and as a response to a specific population. I assume that population is the one that can pay an extra $500/month to have their doctor respond to their every beck and call. Touching all the right spots in a confusing way another quote says,
We wanted the practice to be integrated into the institution.
That last quote is further explained by Dr Jaff:
“We’ve made the institutional commitment that these patients will get the best of the best at a phone call...So if I call and say I need a general surgeon, they’ll have a world-class general surgeon that day.”
I hope that every patient sees a good surgeon the same day if the clinical situation calls for it. All MGH surgeons are theoretically “world class” but what is the process to provide acceptable access for those who are not concierge patients? In a system where the concierge patients buy access to use the same assets as other patients, how are all patients assured of appropriate access?
The article ends with a final justification for the income from concierge medicine. The article reports that the MGH program is designed to benefit us all by sustaining the MGH in hard times. It is the sort of strategy that requires significant PR investment and will choke anyone who has ever read the Annual Cost Trends Report put out by the Massachusetts Health Policy Commission.
“With dwindling reimbursement there needs to be other sources of revenue to help us support our mission to the community at large.”
The idea of wealthy people paying doctors a retainer for exclusive service is not new; why have they waited twenty years? Are they concerned that in the future their successful practice of making everybody pay more will somehow be curtailed?
Yearning for Home
I have been on the road for two weeks as I have hopped from Albuquerque, to San Diego, to Santa Cruz, and then to Cooperstown, New York. I hope to be home a few hours after you get this letter. The picture in this week’s header is from the deck of my son’s home at the edge of a redwood forest in the mountains above Santa Cruz.
During the last two weeks I have seen all kinds of weather and had some amazing walks in beautiful places. Some of my walks have been with a new walking buddy, my nineteen month old grandson. My grandson’s vocabulary now includes something that I believe is “Granddaddy” and he says “more”, “outside”, “all done”, and “Nana” with perfect diction. It the near future I am sure that we will be able to discuss the Triple Aim on our walks as part of the world that is “outside”. I am sure that the work of continuous improvement will not be “all done”.
It looks like I did not miss any exciting weather back in New Hampshire while I was away. The forecast seems to be for a good weekend to be outdoors. I hope that you will be out and about and while you are thinking deep thoughts or in conversation with a friend you will ponder “equity” and just what we would need to do to provide us all with
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time. |
| Be well, stay in touch and keep reaching, working and hoping for the things that you never thought could be possible,
Gene
|
| | | | | |
